I thank Dr. Varghese very much for the kind letter. It is very encouraging that the author is able to offer high-quality cancer care and reconstruction for a very challenging diagnosis in a resource-constrained environment. I applaud Dr. Varghese’s excellent and diligent work.
Dr. Varghese’s comments highlight a fundamental difference in surgical approach to the laryngopharyngectomy defect: the author’s group relies on primary pharyngeal closure or a pectoralis major flap, whereas almost all our patients receive a free flap for neoconduit reconstruction, and many require neck resurfacing. In our patient population, there is rarely any mucosal tissue available for primary closure, and the pectoralis major flap is reserved for resurfacing or salvage of pharyngocutaneous fistulae. In our experience, free flaps provide more reliable skin for tubing a conduit than the pectoralis skin island, which is of variable reliability.
I am not sure what is intended by the statement “our observations with the conventional (pectoralis major and Bakamjian) flaps, both published and archived, are the same as those of the authors.” The first indexed article referred to1 in support of this statement reports closure techniques for laryngopharyngectomy defects with pharyngocutaneous leak rates of 15 to 46 percent, depending on the technique used. The second article referenced2 reports experience with 21 pectoralis myocutaneous flaps with a leak rate of 19 to 40 percent. In our article, of 294 cases, we report a leak rate of 4.5 percent with free flaps and primary neck closure, and 11.3 percent with free flaps and a second flap for resurfacing. The leak rates Dr. Varghese referenced are substantially different and, respectfully, a conclusion of equivalence should not be drawn.
Dr. Varghese also make the statement, that “all attempts at preservation of anatomically and functionally useful unaffected perfused tissues … have a similar protective effect against leaks and fistulae, which in turn can help in decreasing the need for two flaps.” Although this is certainly true, almost all of our laryngectomy defects are performed for locally advanced tumors, salvage of radiation failure, or recurrent disease. In the vast majority of cases, little to no mucosa is preserved, heavy doses of radiation are delivered, and bilateral neck dissections are always performed. Frankly, many of the necks are already “frozen.” In these cases, there is almost no unaffected tissue anywhere in the neck, which is why we rely on free flaps and why resurfacing is so often necessary—and to come back to the original conclusion of the article, why addition of vascularized tissue for resurfacing substantially lowers our already low fistula rates.
The author has no financial interest to declare in relation to the content of this communication.
Jesse C. Selber, M.D., M.P.H.Department of Plastic SurgeryM. D. Anderson Cancer Center1400 Pressler Street, Unit 1488Houston, Texas firstname.lastname@example.org
1. Varghese BT, Babu S, Desai KP, et al. Prospective study of outcomes of surgically treated larynx and hypopharyngeal cancers. Indian J Cancer 2014;51:104108.
2. Varghese BT, Sebastian P, Koshy CM, Ahammed I. Primary laryngopharyngeal reconstruction using pectoralis major myocutaneous flaps: Our experience. Indian J Otolaryngol Head Neck Surg. 2003;55:251254.